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R  D682  P79  Exsection  ol  the  hip 


RECAP 


POORr 


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^xsf^otion  of   bhe  Hin--ioint 


RD68.? 


£Z1 


inti)fCitpoflrttig0rk 
College  of  ^fjpsficiansf  anb  burgeons 


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EXSE(JT10N 


THE    HIP- JOINT. 


G.   T.   FOORE,  M.  D., 


SURGEON  TO  9T.  MABY'9  FBE£  HOSPITAL    FOR  CHILDREN,  AND  CHARITY  HOSPITAL, 
NEW  YORK. 


YBEPRINTED  FROM  THE  NEW  YORK  MEDICAL  JOURNAL,  MAY,  1S7T.] 


NEW     rOKK: 
D.     Al'PLETON     k     COMPANY, 

r.  4  <)     .'t     5  5  1     BROADWAY. 
1877. 


M  E  D  I  C  A  L     W^  O  R  K  S 

PUBLISHED  BY  D.  APPLETON  &  00. 

Anstie  on  Neuralgia,     i  vol ,  i2mo <  Inth,  |2  50 

Bartholow's  Treatise  on  Therapeutics 5  00 

Barker  on  Puerperal  Diseases.     1  vol 5  00 

Barker  on  Sen-Sickness.     1  vol.,  Kiiiio 75 

Barnes's  Obstetric  Operations.     1  vol.,  Hvo 4.50 

Bellevue  and  Charity  Hospital  Reports,     i  vol.,  Svo t  Ui 

Bonnets  Wintsr  and  Sprin.sr  on  the  Mediterranean.    1  vol.,  liuio —  :i  50 

Bennet  on  the  Treatment  of  Pulmonary  Consumption.     1  vol.,  8vo 1  50 

BiUroth's  General  Surg-ical  Pathologry  and  'iherapeutics.     l  vol..  8vo —  5  00 

Buck's  Contributions  to  Reparative  Surgery     1  vol..  !•  vo .S  oo 

Bastian  on  the  Common  Forms  of  Paralysis  from  Brain  Diseases 1  75 

Biilkley's  (L,  D.)  Acne;   its  Pathology,  etc iln  f/remi.ji 

Combe  on  the  Management  of  Infancy.     1  vol.,  Unu) Cloth,  1  50 

Carpenter's  Mental  Physiology "  8  00 

Chauveau's  Comparative  Anatomy  of  the  Domesticated  Animals.    KiV 

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Davis's  (Henry  G,)  Conservative  Surgei-y "  3  00 

Dickson  on  Medicine  in  Relation  to  the  Mind •'  3  50 

Elliot's  Obstetric  Clinic     1  vol.,  Hvo ■•  4  50 

Ecker"s  Convolutions  of  the  Brain "  1  25 

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Flint's  Relations  of  Urea  to  Exercise.     1  vol..  Svo "  1  00 

Frey's  Histology  and  Histo-Chemistry  of  Man        ••  5  00 

Hott'mann's  Mantial  of  Medicinal  Chemicals  '•  3  00 

Holland's  iSir  Henry)  Recollections  of  Past  Liie.     1  vol.,  ]2nio "  2  00 

Howe  on  Emergencies.    1  vol..  Hvo "  3  00 

Howe  on  the  Breath,  and  the  Diseases  which  give  it  a  Fetid  Odor —     "  1  CO 

Huxley  on  the  Anatom.y  of  Vertebrated  Animals.    1  vol "  2  50 

Huxley  and  Youmans's  Physiology  anl  Hyg-isne.    1  vol.,  l2nio "  175 

Hammond's  Insanity  in  its  Relations  to  Crime.     1vol..  Hvo "  100 

Hammond's  Diseases  of  the  Nervous  System.    1  vol.,  8vo..  .(lotli.  Hi  0-:  Sheep,  7  00 

Hammond's  Clinical  Lectures  on  Diseases  of  tKfe  Nervous  System.    1  vol..  8vo,  3  50 

Hamilton's  I  A.  McL>.)  Electro-Therapeutics.    1  vol.,  Hvo Cloth,  2  00 

Johnston's  Chemistry  of  Common  i-iife.    2  vols.,  12nio •■  3  Co 

Keyes's  (E.  L.)  Tonic  Treatment  of  Syphilis "  1  00 

Letterman's  Recollections  of  the  Army  ot  the  Potomac.    1vol.,  8vn ••  i  00 

Lewes's  Physiology  of  Common  Life.    2  vols.,  12ino "  3  00 

Markoe  on  Diseases  of  the  Bones.    1  vol..  Hvo "  4  50 

Maudsley  on  the  Mind.    1  vol.,  Hvo •'  3  50 

Maudsley's  Body  and  Mind.    1  vol.,  12mo •'  100 

Maudsley  on  Responsibility  in  Mental  Disease "  1  50 

Meyer's  Electricity.    1  vol.,  Hvo "  4  00 

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Neumann  on  Skin  Diseases.    1  vol.,  Hvo "  4  00 

New  York  Medical  Journal ;j;4  00  per  animin.    SpeclineD  coulee,  85 

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Schroeder  on  Obstetrics.    1  vol..  Hvo Cloth,  8  50 

Steiner's  Compendium  of  Children's  Diseases "  3  50 

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EXSEOTION 


THE    HIP-JOINT 


C.   T.   POORE,  M.  D., 


SURGEON   TO   ST.   MART'S   FREE   HOSPITAL    FOR    CHILDREN,   AND   CHARITY   HOSPITAt, 

NEW   YORK. 


^REPRINTED  FROM  TEE  NEW  YORK  MEDICAL  JOURNAL,  MAY,  1S7T.] 


NEW    YORK: 
D.     APPLE  TON     &     COMPANY, 

549     &     551     BROADWAY. 

1877. 


71  i 


EXSECTION   OF  THE  HlP-JOmX. 


The  following  cases  are  published  as  a  contribution  ta 
the  study  of  exsection  of  the  hip-joint  in  an  advanced  stage  of 
the  disease : 

Case  I. — Martin  G.,  aged  fourteen  years,  was  admitted 
into  St.  Mary's  Free  Hospital  for  Children,  May  5,  1874,  with 
'the  following  history  :  Six  years  ago  he  fell  upon  the  ice, 
striking  on  his  left  knee,  having  his  leg  in  a  flexed  posi- 
tion. This  was  immediately  followed  by  pain  about  the  hip- 
joint. 

After  some  time  abscesses  formed  and  were  opened,  so 
that  at  the  time  of  admission  there  are  many  sinuses  discharg- 
ing pus  in  the  upper  part  of  the  thigh,  and  gluteal  region. 
The  first  abscess  formed  and  opened  on  the  inner  aspect  of  the 
thigh  near  the  perinaeum. 

On  examination  the  patient  is  rather  pale,  the  left  thigh 
is  flexed  on  the  abdomen  and  adducted.  There  are  four 
fistulous  openings,  one  on  the  inner  aspect  of  the  thigh,  one 
over  the  transverse  process  of  the  lower  lumbar  vertebra?,  two 
on  the  antero-lateral  aspect  of  the  thigh,  and  one  above  Pou- 
part's  ligament.     Dead  bone  can  be  detected  through  most  of 


these  siiiiisefs.  He  Ims  some  pain  <it  iii«:;lit.  There  is  no  albu- 
men in  his  urine.  Appetite  good.  Is  taking  cod-liver  oil 
and  iron. 

On  May  30th,  I)rs.  Watts  and  Mason  assisting,  the  patient 
was  etherized,  and  the  head  of  the  femur  removed,  the  hone 
beinijj  divided  just  above  the  trochanter  minor.  The  shaft  of 
the  fennir  at  this  point  was  perfectly  healtliy.  The  wound 
was  stuffed  with  lint  and  extension  applied. 

The  head  of  the  bone  was  found  much  eroded,  especially 
at  its  inferior  part,  and  the  acetabulum  was  extensively  dis- 
eased and  perforated. 

The  patient  did  well,  and  the  wound  was  closed  by  the 
first  of  September,  except  a  small  sinus,  from  which  there 
is  a  thin,  watiery  discharge ;  no  exposed  bone  can  be  detected. 
A  long  splint  was  applied,  and  patient  allowed  to  go  about. 
He  was  discharged  November  11,  1873,  wearing  a  shoe  with 
a  high  sole.  He  can  bear  his  whole  weight  on  the  limb,  and 
Las  considerable  motion  at  the  hip-joint.  He  walks  without 
a  crutch.     All  the  sinuses  have  closed. 

Itemarka. — It  will  be  noticed  that  in  this  case  the  disease 
was  confined  to  the  bones  immediately  forming  the  joint ; 
that  the  shaft  of  the  femur  at  the  point  of  section  was  perfect- 
ly healthy;  that  there  was  a  sinus  ahove  Poupart's  ligament, 
and  that  the  acetabulum  vf2i?,  perforated.  Also,  that  the  first 
abscess  opened  on  tlie  inner  surface  of  the  thigh  near  the  peri- 
n£eum,  and  that  the  head  of  the  bone  showed  most  disease  at 
its  inferior  part. 

Case  II. — John  II.,  aged  six  years,  was  admitted  into  St. 
Mary's  Hospital,  January  10,  1874.  He  has  had  disease  of 
the  left  hip-joint  for  two  years,  following  a  fall.  He  has  been 
treated  by  extension  by  means  of  a  weight  and  pulley.  Al>out 
one  year  before  admission  an  abscess  formed  on  the  anterior 
aspect  of  the  left  thigh,  and  was  freely  opened ;  later,  another 
formed  on  its  inner  aspect  near  the  perinseum.  He  walks 
with  a  crutch,  and  sufiers  considerable  pain.  On  examination 
sinuses  are  found  as  above,  the  discharge  from  which  is  con- 
siderable. ]S^o  exposed  bone  can  be  detected,  nor  is  there 
any  crepitus  on  motion    at  the  joint,    even   when  the  head 


of  tlie  bone  is  crowded  in.     Sliorteninfi;,  tliree-quarters  of  an 
inch. 

His  general  condition  is  poor.  There  is  no  albumen  in  hi& 
urine.  He  was  put  uj)on  a  good  diet,  and  took  cod-liver  oil 
and  iron.     Under  this  treatment  lie  improved. 

A  short  time  ago  dead  bone  was  found  about  the  joint,  and 
to-daj  lie  was  etherized,  and  the  joint  excised,  Drs.  Watts  and 
Mason  assisting.  The  head  and  neck  of  the  bone  were  found 
much  eroded,  and  the  upper  portion  of  the  acetabulum  eaten 
awa3^  There  was  no  perforation.  Section  was  made  above 
the  trochanter  minor.  The  bone  at  this  point  w^as  soft  and 
discolored.  The  limb  was  placed  in  a  splint  extending  down 
below  the  knee  and  embracing  the  pelvis,  and  extension  ap- 
plied. The  wound  healed,  with  the  exception  of  a  sinus  in  the 
line  of  incision,  through  which  dead  bone  can  be  felt. 

Early  in  the  fall  he  was  up  and  about  the  ward,  wearing  a 
boot  with  a  high  sole,  and  was  able  to  bear  considerable  weight 
on  the  limb.  In  December  the  glands  in  the  groin  became 
affected  with  caseous  degeneration  and  suppurated.  After 
enucleation  the  wound  healed.  In  February,  1876,  the  dis- 
charge from  the  parts  about  the  joint  continuing,  the  line  of 
incision  was  reopened^  and  the  end  of  the  femur  exposed.  It 
was  found  denuded  of  periosteum,  carious,  the  medullary  cavity 
enlarged,  the  bone  of  a  dirty  leaden  color,  and  the  end  rough 
and  irregula,r.  On  crowding  the  shaft  upward  the  periosteum 
was  found  detached  as  far  as  examined  (three  inches),  and  the 
bone  in  the  same  diseased  condition.  About  an  inch  or  more 
was  removed,  the  cut  section  showing  the  same  unhealthy 
condition  of  the  central  portion  as  at  point  of  first  section. 
It  was  evident  that  the  disease  involved  the  greater  portion  of 
the  shaft.  The  wound  healed,  with  the  exception  of  a  small 
sinus.  The  patient  was  discharged  May  30,  1876.  He  was 
able  to  walk  w^ith  the  aid  of  a  crutch.  He  suffers  no  pain. 
Shortening,  two  inches.     He  has  enlargement  of  the  liver. 

Patient  presented  himself  at  the  hospital,  December  26, 
1876.  His  general  condition  is  about  the  same  as  when  he 
left.  He  still  uses  a  crutch,  and  complains  of  some  pain  about 
the  hip-joint  on  pressure.  The  sinus  still  discharges  a  little, 
and  there  is  dead  bone. 


RemarJis. — Tli>s  was  a  case  ot'lonoj  duration.  The  disease 
was  confined  cliieily  to  the  head  of  the  bone,  the  acetabiihini 
1)01112^  or\\y  eroded  on  its  upper  surface.  The  shaft  of  the 
femur  was  soft  and  discolored  at  tlie  ])oint  of  section  at  tlje 
time  of  tlie  operation.  The  wound  healed,  with  the  exception 
of  a  sinus  coninninicatin<;  with  diseased  hone.  After  some 
time  the  line  of  incisiou  was  opened.  The  periosteum  was 
found  retracted  from  the  end  of  the  Ijoiie,  which  was  much 
eroded.  Attempt  was  made  to  remove  the  diseased  portion 
of  the  shaft,  but,  after  exposing  it  for  about  three  inches, 
it  was  still  found  to  be  of  a  dirty  color,  the  penosteurn  but 
loosely  attached,  and  on  sectiou  the  bone  was  soft,  and  the 
medullary  cavity  showiuo;  the  same  diseased  condition  as  at 
point  of  first  section.  There  did  not  appear  to  be  any  pus 
between  the  periosteum  and  the  bone,  nor  had  there  been  any 
attempt  at  the  formation  of  an  involucrum.  Notwithstanding 
the  amount  of  disease  in  the  joint,  no  crepitus  could  be  de- 
tected on  account  of  the  granulations  in  the  acetabulum. 

Case  III. — Willie  C,  two  and  a  half  years  old,  was  ad- 
mitted into  St.  Mary's  Free  Hospital,  December  1,  1873,  with 
the  following  history :  About  four  months  before  being 
brought  to  the  hospital  he  fell  down-stairs,  after  which  his 
mother  noticed  that  he  did  not  attempt  to  walk  ;  he  com- 
plained of  pain  on  any  motion  of  the  right  limb  ;  he  soon  be- 
came restless  at  night  and  cried  out  in  his  sleep.  At  the  time 
of  his  admission  is  pale,  and  his  appetite  poor,  (3n  examina- 
tion there  is  found  considerable  swelling  of  the  tissues  about 
the  right  hip-joint ;  the  limb  is  flexed,  and  rotated  inward.  He 
complains  of  pain  on  pressure  over  the  joint,  and  upon  any 
motion  of  the  limb.  He  had  extension  applied,  and  was 
ordered  iron,  and  to  have  hot  water  ap[)lied  to  the  joint  twice 
a  day. 

After  some  weeks  the  tissues  about  the  joint  broke  down, 
and  an  abscess  formed  and  was  opened.  His  general  condi- 
tion did  not  improve;  the  joint  continued  very  painful,  and 
his  sleep  at  night  was  disturbed. 

In  April,  1874,  the  joint  was  excised  ;  the  liead  of  the 
bone  was  extensively  diseased,  the  acetabulum  but  slightly 
affected.     Section  was  made  just  above  the  trochanter  minor. 


\ 


1 

The  bone  looked  perfectly  healthy  at  point  of  section;  quite 
a  large  piece  of  fibrous  tissue  above  the  joint  was  united  to 
the  soft  parts  on  the  shaft  of  the  femur.  I  was  assisted  at 
the  operation  by  Drs.  Watts  and  Mason.  He  was  relieved 
from  all  pain  ;  rested  better  the  night  after  the  operation  than 
he  liad  done  since  his  admission.  He  improved  for  a  short 
time,  but  soon  there  was  bagging  of  pus,  which  it  was  impos- 
sible to  prevent.  He  soon  developed  disease  of  the  lungs,  and 
died  October  14,  1874. 

On  post-mortem  examination  the  upper  end  of  the  femur 
was  found  rough  and  carious.  The  shaft  was  denuded  on 
inner  aspect  for  about  two  inches  below  the  point  of  section, 
"being  the  track  of  an  abscess  which  extended  from  the  acetab- 
ulum down  on  the  inner  aspect  of  the  thigli  to  its  middle. 
The  end  of  the  femur,  which  was  enlarged,  is  lirmly  held  in 
the  cavity  of  the  acetabulum.  There  is  an  exostosis  on  the 
femur  corresponding  to  the  lower  border  of  the  acetabulum. 
The  bone  is  not  denuded  of  periosteum,  except  at  the  above- 
mentioned  point.  The  acetabulum  was  not  perforated,  but 
extensively  diseased.  The  band  of  fibrous  tissue  which  was 
united  to  the  soft  parts  on  the  femur  was  evident  as  a  strong 
band  closing  up  the  joint-cavity. 

Remarks. — It  will  be  noticed  that  the  shaft  of  the  femur 
was  healthy  at  the  point  of  section ;  that  the  end  of  the  bone 
at  the  post-mortem,  examination  was  found  enlarged  j  that 
the  periosteum  was  not  detached^  and  that  there  were  oste- 
ophytes on  the  surface  of  the  bone.  I  think  that  joining  the 
shaft  to  the  parts  above  by  the  piece  of  fibrous  tissue  was  a 
mistake,  as  it  tended  to  close  up  the  joint-cavity  and  pre- 
vented the  free  discharge  of  pus.  I  do  not  know  whether  it 
had  any  influence  on  the  result,  but  it  certainly  M^as  not  a 
gain. 

Case  IY. — Amanda  G.,  aged  three  and  a  half  years,  was 
admitted  into  St.  Mary's  Hospital,  Marcli  12,  1875,  witli  the 
following  history :  Eighteen  months  ago  she  complained  of 
pain  in  her  right  foot,  and  walked  with  a  limp  for  a  few  days, 
when  she  refused  to  walk  at  all.  She  was  treated  by  exten- 
sion, but  did  not  improve.  Six  months  ago  an  abscess  ap- 
peared on  the  external  aspect  of  the  thigh,  and  opened  about 


8 

three  inches  below  the  trochanter;  tliis  hius  continued  to  dis- 
chari^e  profusely  ever  since,  ller  mother  can  assign  no  cause 
for  the  trouble.  On  examination,  there  is  found  a  sinus  as 
above,  from  which  there  is  a  profuse  discharge  of  healthy-look- 
ing })us.  Both  limbs  are  plump,  and  no  difference  in  their 
size  can  be  detected  ;  there  is  no  pain  along  the  shaft  of  the 
femur  on  pressure.  The  right  thigh  is  flexed  somewhat  on 
the  abdomen.  Crepitus  can  be  detected  by  crowding  the 
head  of  the  bone  inward  ;  no  exposed  bone  can  be  found.  Pa- 
tient is  a  blonde,  and  seems  to  be  in  good  condition ;  appetite 
fair.     Extension  applied. 

April  21,  1875, — Patient  was  to-day  etherized,  and,  as- 
sisted by  i)r.  Watts,  I  made  the  usual  incision  over  the 
trochanter,  and  exposed  the  bone.  In  attempting  to  throw 
the  head  of  the  bone  out  of  the  acetabulum  the  femur  was 
fractured  at  the  junction  of  the  diaphysis  with  the  e[)iphysis, 
just  above  the  knee-joint.  Tlie  head  of  the  bone  was  re- 
moved from  the  acetabulum  after  section,  just  above  tro- 
chanter minor.  On  examination  of  the  cut  end  of  the 
bone,  it  was  found  to  be  soft,  discolored,  the  periosteum  being 
easily  separated,  and  on  crowding  the  end  of  the  bone  up  in 
order  to  see  the  extent  of  the  disease,  the  same  condition  was 
found.  It  remained  either  to  amputate  at  the  hip-joint,  or  to 
remove  the  whole  shaft  of  the  femur  :  as  the  patient  was 
apparently  in  good  condition,  the  latter  was  decided  upon. 
This  was  easily  done,  the  whole  shaft  being  drawn  bv  traction 
through  the  original  incision.  There  was  no  haemorrhage,  nor 
was  the  periosteum  attached  at  any  point.  The  fracture  was 
found  to  have  taken  place  obliquely  from  within  outward 
and  from  behind,  forward,  leaving  a  small  portion  of  the  ex- 
ternal condyle  attached  to  the  epi])hysis,  but  dead.  The  ace- 
tabulum was  perforated ;  the  upper  portion  of  the  wound  was 
brought  together  with  suture,  leaving  a  sufficient  opening  for 
tlie  discharge ;  no  involucrum  had  formed.  Tlie  limb  was 
placed  between  sand  pillows,  and  extension  (four  pounds)  ap- 
plied. 8  p.  M.,  patient  comfortable,  does  not  complain  of  any 
pain  ;  pulse  128  and  good  ;  temperature  10(>.5°. 

22<:7. — Comfortable  ;  temperature  10<>.5°,  pulse  13(3,  a.  m.  ; 
temperature  100.5°,  pulse  142,  r.  m. 


\) 

23r/. — Wound  dressed ;  no  pain  nor  swelling  ;  pulse  120, 
temperature  100.2°,  a.  m.  ;  pulse  130,  temperature  100.2°,  r.  m. 

24:ih. — Discharge  from  cavity  of  periosteum  free  and  con- 
siderable ;  appetite  good;  quinine  gr.  ij  every  three  hours; 
plenty  of  milk  and  eggs;  pulse  104,  temperature  98.5°,  a.  m.  ; 
pulse  100,  temperature  100.2°,  p.  m. 

25tk. — Doing  well,  discharge  not  any  more  profuse  than 
before  the  operation  ;  appetite  good  ;  pulse  116,  temperature 
98.7°,  A.  M. ;  pulse  120,  temperature  101.8°,  p.  m. 

26th. — Seems  brighter,  takes  her  nourishment  well ;  no 
pain  ;  wound  looks  well  ;  pulse  116,  temperature  99.8°,  a.  m.  ; 
pulse  140,  temperature  100.8  ,  p.  m. 

This  evening  her  face  was  noticed  to  be  swollen  on  the 
left  side,  but  she  made  no  complaint  until  11.30  p.  m.,  at  which 
time  there  was  found  some  swelling  in  the  left  side  of  the 
mouth  on  either  side  of  the  alveolar  process  of  superior  max- 
illa ;  there  was  no  tenderness.  She  can  open  and  shut  her 
mouth  freely ;  there  is  also  some  swelling  on  the  cheek  cor- 
responding to  the  position  of  the  swelling  in  the  mouth. 
Ordered  tr.  ferri  chlor.  x  every  three  hours.  She  has  had 
no  chill ;    temperature  103°,  pulse  140. 

271/1. — Pulse  128,  temperature  101.5°,  a.  m.  ;  pulse  116,  tem- 
perature 99°,  p.  M. 

2Si^A. — The  swelling  on  the  side  of  face  has  increased,  the 
skin  looks  glossy,  no  pain  on  pressure.  On  examining  mouth 
the  first  and  second  molar  teeth  are  found  loose,  the  second 
carious ;  thinking  that  this  might  be  the  cause  of  the  trouble, 
they  were  removed.  Pulse  100,  temperature  99.2°,  a.  m.  ;  pulse 
120,  temperature  101°,  p.  m. 

29th. — Swelling  ot"  face  more  marked  ;  still  nothing  can  be 
found  to  account  for  the  trouble.  Appetite  good,  wound  dis- 
charging freely,  no  bagging,  pus  perfectly  healthy  looking. 
The  edges  of  the  wound  are  beginning  to  cicatrize ;  they  look 
perfectly  healthy.  Pulse  118,  temperature  99.8°,  A.  m.  ;  pulse 
128,  temperature  111°,  p.  m. 

30^A. — Pulse  130,  temperature  99.5°,  a.  m.  ;  pulse  132,  tem- 
perature 102.5°,  p.  M. 

3Iay  1st. — Pulse  140,  temperature  102.5°,  a.  m.  ;  pulse  144, 
temperature  102°,  p.  m. 


2(1. — Pulse  12-i,  temperature  100°,  a.  m.  ;  pulse  140,  tem- 
perature 101.2,  p.  M. 

3^7.— Pulse  128,  temjK'rature  1(»0.2  ,  a.  m.  ;  pulse  14(>,  tem- 
perature 100,2°,  V.  M. 

Since  last  note,  i)atient  has  continued  in  about  the  same 
condition,  with  the  exception  that  the  swellini:;  of  the  face  is 
more  marked,  so  as  to  close  the  left  eye  ;  Vtreath  otiensive.  On 
examining  the  mouth  to-day  there  was  found  a  slough  of  the 
inner  portion  of  the  cheek,  just  where  the  mucous  membrane 
is  reflected  off  from  the  gums.  The  fluger  can  be  passed 
through  this  opening,  and  carried  all  over  the  external  surface 
of  the  superior  maxilla,  which  is  denuded  of  periosteum,  and 
dead.  This  cavity  is  syringed  out  with  carbolic  acid  and 
water.  The  general  condition  of  patient  about  the  same ;  the 
wound  looks  w^ell ;  the  skin  under  the  eye  and  a  little  below 
the  outer  angle  of  the  lid  looks  thin  and  discolored.  Ordered 
whiskey,  3  iij. 

■^th.  —  Breath  very  offensive;  cavity  syringed  out;  the 
wound  still  looks  w-ell,  but  perhaps  the  granulations  are  not  as 
bright.  Pulse  140,  temperature  100.5°,  a.  m.  ;  pulse  148,  tem- 
perature 100.9°,  p.  M. 

hth. — Face  is  no  better;  breath  offensive;  respirations 
rapid ;  takes  her  nourishment  well.  The  finger  can  now  be 
passed  back  behind  the  superior  maxilla  into  the  spheno-max- 
illary  fossa.  Pulse  inclined  to  be  w^eak  and  rather  sharp.  A 
small  opening  has  formed  on  her  cheek  about  one  inch  below 
the  outer  canthus  of  eye.  Pulse  124,  temperature  100,5°, 
A.  M. ;  pulse  120,  temperature  101°,  p.  m. 

Qth. — Considerable  sloughy  tissue  removed  through  the 
opening  in  cheek ;  cavity  disinfected  ;  wound  in  thigh  looks 
badly,  but  discharge  healthy  ;  respiration  28.  Pulse  140,  tem- 
perature 100.2°,  A.  M. ;  pulse  140,  temperature  100.5°,  p.  m. 

^th. — No  change ;  more  tissue  removed  from  cheek.  Pulse 
148,  temperature  101°,  a.  m.  ;  pulse  140,  temperature  100.9°, 
p.  M. 

8^A.— Pulse  140,  temperature  99.5°,  a.  m.  At  10  this 
morning  she  seemed  brighter ;  called  for  some  milk ;  voice 
strong.  On  going  to  her  she  seemed  to  have  some  difficulty 
in  breathing,  and  immediately  died. 


11 

Pof^t  Mortew,. —  Only  tlie  lini])  extimined.  The  whole  ot  the 
periosteu7Tj  was  removed,  including  the  epiphysis.  The  knee- 
joint  was  perfectly  healthy.  The  limb  is  much  stiffer  than  at 
time  of  operation.  There  is  found  a  deposit  of  bone  about 
three  inches  long,  and  varying  in  width  not  anywhere 
more  than  one-quarter  of  an  inch.  The  epiphysis  is  perfectly 
healthy.     No  other  part  examined. 

Remarks. — It  seems  strange  that  there  should  have  been 
so  much  disease  with  so  few  symptoms.  There  was  no  ten- 
derness over  the  femur  on  pressure,  and  not  mucli  about  the 
hip-joint.  From  the  fact  that  the  acetabulum  was  so  exten- 
sively diseased  and  perforated,  the  disease  must  have  begun 
in  the  joint,  and  extended  to  the  shaft.  The  occurrence  of 
disease  of  the  superior  maxilla,  with  extensive  sloughing  of  the 
periosteum,  I  am  unable  to  assign  any  cause  for.  The  range 
of  temperature,  absence  of  cliill  and  sweating,  the  general 
condition  of  the  patient,  the  healthy  state  of  the  wound  nntil 
two  days  before  death,  and  the  absence  of  any  approach  to  a 
typhoid  condition,  would  seem  to  negative  the  idea  of  pysemia. 
A  temperature  of  99o5°  just  before  death  does  not  seem  com- 
patible with  the  supposition  that  she  was  suffering  from  puru- 
lent infection. 

Case  Y. — Katy  M.,  aged  six  years,  was  admitted  into  St. 
Mary's  Hospital  for  Children,  January  5,  1876.  Had  been 
suffering  from  disease  of  left  hip-joint  for  two  years.  She  first 
complained  of  pain  in  the  knee,  and  after  two  months  began 
to  limp,  and  then  almost  immediately  ceased  to  walk.  Six 
months  later  an  abscess  opened  on  the  anterior  aspect  of  the 
thigh.  Three  other  openings  formed  before  the  date  of  ad- 
mission. When  examined,  she  showed  all  the  symptoms  of 
hip-disease  in  the  third  stage.  Joint  painful ;  patient  cries 
out  with  pain  at  night,  and  cannot  bear  to  be  moved.  Tiie 
left  thigh  is  flexed  on  the  abdomen ;  there  is  considerable 
swelling  about  nates  ;  her  general  condition  is  poor  ;  no  albu- 
men in  urine  ;  ordered  iron  and  extension. 

A  large  abscess  was  aspirated  January  12th,  and  again  on 
the  30th  of  January  and  1st  of  February. 

As  the  patient  seemed  to  be  losing  ground  from  the  pain 
and  profuse  discharge,  the  joint  was  excised  February  4th — 


present,  Drs.  Peters  uiid  Watts — tlio  bono  Iumiij^  divided  just 
above  the  trochanter  niiiior.  Tlie  head  of  tlie  feinnr  had  en- 
tirely disappeared,  with  tho  exception  of  a  lon<;  Bpiko  extend- 
ing into  the  joint  cavity,  which  was  filled  with  loose  frag- 
ments. The  bone,  at  the  point  of  section,  was  soft  atid  dis- 
colored. There  was  an  abscess  pointing  above  Poupart's 
ligament.  The  acetabnliim  was  perforated,  readily  admitting 
the  linger.     Patient  was  placed  in  a  wire  cuirass. 

She  rapidly  improved  after  the  operation,  although  the 
discharge  continued  profuse.  In  March  the  upj)er  half  of  the 
thigh  became  swollen  and  looked  glossy,  and  the  deep  tissue 
seemed  thickened. 

March  2i)th. — The  u])per  portion  of  the  femur,  as  felt 
through  the  wound,  is  denuded  and  thinned.  How  far  it 
extends  it  is  impossible  to  say.  Iler  general  condition  has 
greatly  improved.  Her  temperature  (evening)  varies  from 
100°  to  101^ 

June  10th. — She  is  to-day  etherized,  and  the  end  of  the 
bone  is  exposed.  It  is  found  soft  and  dark-colored  ;  the  perios- 
teum separated,  and  the  bone  carious.  About  one  and  a  half 
inch  was  removed.  There  is  disease  farther  down.  General 
condition  continues  good. 

January  9,  1877. — She  is  up  and  about ;  the  parts  about 
the  joint  are  thickened,  and  there  is  considerable  stiiihess ;  dead 
bone  can  be  detected,  w4iich  seems  to  be  the  end  of  the  femur. 
There  is  no  pain  about  the  parts  on  crowding  the  bone  up. 
There  is  a  sinus  leading  down  to  the  diseased  shaft,  from 
which  there  is  considerable  discharge.  General  nutrition  of 
the  limb  good  ;  it  is  as  large  as  the  other.  No  tenderness 
along  the  course  of  the  femur.     The  liver  is  enlarged. 

ReriiarTis. — It  will  be  noticed  that  the  disease  in  tliis  case 
was  at  an  advanced  stage ;  that  there  was  an  abscess  pointing 
aljove  Poupart's  ligament,  and  that  the  acetdbulum  was  per- 
forated;  that  the  femur  at  the  point  of  section  was  soft  and 
discolored,  and  that  at  a  subsequent  period  the  wound  was 
opened,  and  an  attempt  made  to  remove  the  diseased  portion 
of  the  femur  ;  but  the  disease  was  found  to  extend  too  far 
down  ;  that  the  periosteum  was  not  intimately  attached  to 
the  bone,  to  the  limit  of  the  portion  of  the  bone  examined, 


and  tliat  on  section  the  same  Hi)pearance  of  tlie  shaft  was  found 
as  at  point  of  first  section.     The  end  of  tlie  bone  was  eroded. 

Case  YI, — James  C,  fifteen  years  of  age,  was  admitted 
into  St.  Mary's  Hospital  tor  Children,  March  14-,  1870.  Tie 
gives  the  following  history  :  Three  years  ago  he  had  frequent 
falls,  followed  by  limping  and  pain  in  right  knee  ;  he  was  in 
a  hospital  for  two  and  a  half  years,  during  which  time  quite 
a  number  of  abscesses  formed  and  opened  spontaneously.  At 
the  time  of  his  admission  the  right  thigh  is  flexed,  shortened, 
and  inverted  ;  the  knee-joint  is  also  flexed  and  stiff.  He  suf- 
fers much  pain,  so  that  he  is  contined  to  the  bed  most  of  the 
time ;  he  lies  in  bed,  propped  up  with  pillows  ;  he  has  not 
been  able  to  lie  down  for  two  years.  There  are  four  sinuses 
about  the  joint,  through  most  of  which  dead  bone  can  be  felt. 
There  is  considerable  discharge.  Patient  is  thin  and  pale ; 
appetite  poor;  liver  enlarged.  There  is  some  albumen  in 
his  urine,  but  no  casts  can  be  found. 

On  May  21st  the  joint  was  excised — present,  Drs.  Peters 
and  Watts.  The  head  of  the  bone  was  found  lying  in  the 
cavity  of  the  acetabulum  in  pieces  ;  the  neck  was  also  splin- 
tered ;  the  bone  was  divided  below  the  trochanter  minor ; 
the  shaft  was  found  extensively  diseased  ;  the  bone  was  soft, 
thin,  dark-colored,  and  the  medullary  cavity  enlarged,  so  as  to 
easily  admit  the  finger  for  two  or  more  inches  ;  the  shaft  was 
divided  again  lower  down  ;  the  periosteum  w^as  loose  ;  the 
condition  of  the  bone  at  the  point  of  second  section  showed 
the  same  diseased  condition.  The  acetabulum  was  not  per- 
forated, and  but  slightly  diseased. 

Wound  brought  together  in  part,  and  patient  placed  in  a 
cuirass,  with  extension  so  as  to  bring  the  knee  down. 

In  July  all  the  wound  had  closed  except  a  sinus  in  the 
middle  of  the  line  of  incision,  through  which  the  denuded  end 
of  the  femur  can  be  felt ;  the  discbarge  is  verj'  slight. 

December  14:th. — The  patient  has  been  about  the  ward  for 
some  months  on  crutches.  He  has  been  troubled  with  exces- 
sive osdema  of  the  whole  limb,  which  bandaging  has  relieved. 
To-day  he  has  a  high  sole  on  his  shoe.  He  cannot  bear  much 
weight  upon  the  limb  on  account  of  his  knee  giving  away. 
There  is  no  pain  about  the  hip-joint,  and  he  has  some  fair 


14 

aniouiit  of  rif.xinii  ;iiul  extension.  There  has  ])een  no  albumen 
since  the  operation, 

RtHiarks. — It  will  he  noted  that  there  was  extensive  dis- 
ease of  the  shaft  of  the  femur;  that  it  was  of  a  fluyk  color ^  and 
soft  ',  tliat  tlie  periosteum,  was  not  intimately  attached  to  it; 
that  the  medullary  cavitv  was  enlarged ;  that  on  making  a 
second  section  the  same  diseased  condition  of  the  hone  was 
found  ;  that  there  was  no  sinus  or  abscess  above  Poupart's 
lio;ament ;  and  that  the  acetabulum  was  not  perforated.  The 
occurrence  of  albumen  is  worthy  of  note,  as  well  as  the  en- 
largement of  the  liver. 

Case  VII. — Ma)'  F.,  three  years  of  age,  was  brought  to 
St.  Mary's  Free  Hospital  for  Children,  March  25,  1875.  Two 
months  previous  she  had  a  fall  while  on  board  a  steamer,  and, 
when  she  arrived  in  New  York,  was  lame.  She  dragged  the 
toes  of  the  left  foot,  and  complained  of  pain  in  her  knee.  On 
admission  she  presented  the  symptoms  of  disease  of  the  left 
hip-joint ;  tenderness,  lordosis,  and  sw'clling.  Tiiere  is  a  spot 
of  rupia  about  the  size  of  a  silver  quarter  of  a  dollar  on  her 
forehead.  She  is  pale,  of  a  blonde  complexion.  She  was  put 
on  iron,  had  extensioif  applied,  and  hot  water  to  the  joint. 

Swelling  and  tenderness  disappeared,  and  in  July  a  long 
splint  was  applied,  and  she  was  allowed  to  go  about  the  ward. 
She  has  had  several  attacks  of  eczema  under  the  plaster,  so 
that  at  times  it  had  to  be  removed.  She  has  also  had  attacks 
of  pemphigus  over  her  whole  body,  but  most  marked  on  the 
palms  of  her  hands  and  soles  of  her  feet.  In  December,  1875, 
an  abscess  formed  on  the  anterior  aspect  of  thigh,  just  below 
Poupart's  ligament,  outside  of  the  vessels  ;  this  was  aspi- 
rated, and  about  an  ounce  of  pus  obtained  ;  it  seemed  super- 
ficial, and  I  do  not  think  it  communicated  with  the  joint. 
Slie  was  about  again  in  a  few  weeks.  In  the  latter  part  of 
March,  1876,  the  posterior  aspect  of  the  thigh  (upper  portion) 
was  found  to  be  swollen,  and  upon  examination  fluctuation 
was^evident.  She  had  complained  of  no  pain,  and  the  abscess 
was  only  accidentally  discovered.  This  was  aspirated  on  the 
23d  and  again  on  the  26th.  There  then  appeared  some  swell- 
ing on  the  anterior  aspect  of  the  thigh,  below  position  of  the 
former  abscess  ;   the  fluctuation  seems  deep.      On  the  29th 


15 

the  abscess  on  the  posterior  aspect  of  tliigli  was  freely  opened, 
as  aspiration  did  not  seein  to  relieve  it  sufficiently.  Patient 
was  feverish  ;  tongue  coated. 

April  15th. — Abscess  opened  on  anterior  aspect  of  tliigh. 
There  is  a  communication  between  the  two  aljscesses. 

June  SOth. — Patient  has  been  losing  ground  ;  abscess  dis- 
charging profusely  ;  the  pus  does  not  seem  to  come  from  the 
ioint ;  a  probe  passed  into  either  opening  seems  to  y)ass  tow- 
ard the  inner  and  deeper  portions  of  the  thigli, 

Septemher  15th. — On  account  of  the  hot  weather,  nothing 
has  been  done.  She  has  improved  somewhat  since  the  first 
of  the  month.  There  is  some  bony  crepitus  in  the  joint. 
To-day  she  was  placed  under  ether  (present,  Drs.  Peters, 
Watts,  and  Yale) ;  dead  bone  can  be  detected  on  the  inner 
aspect  of  the  femur,  about  an  inch  and  a  half  below  the  joint. 
Thei'e  are  two  openings  on  the  postero-lateral  portion  of  the 
thigh,  which  are  united  by  a  free  incision,  so  that  the  finger 
can  be  made  to  enter  the  joint,  which  is  found  diseased.  The 
soft  parts  were  separated  from  the  bone,  and  the  head  easily 
thrown  out.  It  was  then  found  that  the  inner  aspect  of  the 
shaft  anterior  to  the  trochanter  minor  was  extensively  eroded, 
so  that  only  a  thin  shell  of  bone  was  left,  corresponding  to  the 
outer  aspect  of  the  femur.  The  head  had  nearly  disappeared, 
and  the  cavity  of  the  acetabulum  was  filled  with  loose  pieces 
of  bone,  and  was  extensively  diseased,  but  not  perforated. 
The  shaft  was  divided  below  the  point  of  disease,  when  after 
section  the  bone  seemed  healthy.  The  upper  and  outer  edge 
of  the  acetabulum  was  most  diseased,  and  a  portion  removed  ; 
but,  on  account  of  the  condition  of  the  patient,  it,  was  thought 
best  to  desist  from  any  further  gouging  of  bone.  There  was 
an  extensive  abscess  on  the  inner  side  of  the  ileum,  which  was 
pointing  just  within  the  crest.     Whiskey,  etc. 

26^A. — Passed  a  comfortable  night  ;  put  into  wire  cuirass 
to-day  ;  made  no  complaint  of  pain.  Abscess  near  crest  of 
ileum  open  to-day. 

October  2>d. — Wound   cicatrizing;    discharge    moderate 
spicula  of  bone  discharged. 

5th. — Drainage-tube  inserted. 


in 

On  probing,  dead  hone  is  found  through  the  opening  near 
crest  of  ileum,  situated  about  the  rim  of  the  pelvis. 

December  XiMh. — Wound  does  not  close  ;  discliarge  moder- 
ate ;  no  bagging  ;  patient's  general  condition  good ;  she  suf- 
fers no  pain. 

January  IG,  1877. — The  diseliarge  has  been  increasing  for 
some  days.  To-day  etherized  patient  in  order  to  make  a  thor- 
ough examination  of  the  parts.  The  end  of  the  femur  is  found 
denuded,  and  the  edge  of  the  bone  irregular.  The  compact 
tissue  has  not  been  thinned  as  much  as  in  the  other  cases. 
The  bone  about  the  acetabulum  is  extensively  diseased.  The 
whole  bone  from  the  anterior-superior  spine  of  the  ileum 
down  to  the  ischium  seems  to  be  in  a  carious  condition. 
The  bone  is  soft,  so  that  it  can  be  scraped  off  with  the  finger- 
nail ;  a  considerable  portion  was  removed  with  forceps  and 
rongeur.  A  piece  of  bone  about  the  size  of  a  filbert  was 
found  loose  near  the  tuberosity  of  the  ischium.  An  opening 
was  made  so  as  to  /afford  a  free  escape  of  pus  from  the  diseased 
bone. 

On  section  of  the  portion  of  bone  removed,  it  was  found 
affected  with  articular  osteitis.  The  cartilage  had  disappeared, 
and  but  a  small  stump  of  the  neck  remained.  The  line  of 
junction  between  the  shaft  and  the  trochanter  major  was  dis- 
eased, and  a  portion  of  the  cartilaginous  trochanter  was  loose. 
The  disease  seems  to  have  extended  down  the  centre  of  the 
bone,  and  to  have  entirely  destroyed  the  whole  inner  surface 
of  the  compact  tissue  of  the  shaft  just  anterior  to  the  tro- 
chanter minor.  The  compact  tissue  below  the  trochanter  ma- 
jor was  very  thin,  and  had  a  worm-eaten  appearance. 

Remarks. — It  is  probable  that  the  disease  in  this  case  be- 
gan in  the  head  of  the  bone  as  an  articular  osteitis,  and  that  it 
extended  down  the  shaft.  The  existence  of  hereditary  syphilis 
is  rendered  probal^le  by  the  rupia  and  pemphigus  on  the  feet 
and  hands.  There  was  an  abscess  above  Poupart's  ligament, 
but  no  perforation  of  the  acetabulum.  There  was  disease  of 
the  rim  of  the  pelvis. 

In  looking  over  the  histories  of  these  seven  cases,  it  will  be 
noticed  that  they  were  all  in  an  advanced  stage  of  the  disease ; 
that  from  the  condition  of  the  bone  a  cure  by  means  of  rest 


17 

and  luocliaiiicul  support  was  impossible  ;  and  that,  iinic.-s  re- 
lief from  the  pain  and  irritation  was  afforded,  a  speedily  fatal 
termination  was  inevitable.  Exsection  of  the  joint  afforded  a 
chance,  and,  even  if  not  succespfnl  in  giving  a  sound  limb, 
afforded  immediate  relief  from  all  pain,  and  made  what  re- 
mained of  life  comfortable. 

In  four  cases  the  shaft  of  the  femur  was  diseased  below  the 
point  of  section,  namely,  in  Cases  II.,  IV.,  V.,  and  VI.  In 
Case  IV.  the  whole  diaphysis  was  removed,  while  in  two 
cases,  JSTos.  II.  and  Y.,  after  some  months  the  wound  was 
opened  and  a  further  section  made  of  the  bone.  Notwith- 
standing the  unhealthy  condition  of  the  shaft  in  Cases  II.,  IV., 
v.,  VI.,  the  wounds  healed,  but  with  a  sinus  leading  down 
to  the  end  of  the  diseased  bone;  and  the  patients  were  able  to 
go  about  the  ward,  and  out,  witli  the  assistance  of  a  crutch, 
without  any  pain.  Case  I.  was  discharged  with  the  wound 
and  all  the  sinuses  healed  ;  no  dead  or  exposed  bone  could 
be  found  ;  and  able  to  go  about  without  a  crutch.  Cases  III. 
and  IV.  died  :  one  from  secondary  disease  in  the  superior  max- 
illa, and  the  other  from  phthisis.  All  the  patients  (except 
III.  and  IV.)  are  able  to  bear  considerable  weight  on  the  dis- 
eased limb,  and  complain  of  no  pain  upon  pressure.  In  Case 
V.  the  limb  is  stiff  at  the  hip-joint,  and  since  the  bandage  has 
been  removed  has  increased  in  size,  and  is  as  large  as  the 
other. 

The  diagnostic  value  of  an  abscess  or  sinus  above  Poupart's 
ligament,  indicating  perforation  of  the  acetabulum,  as  pointed 
out  by  Barwell  in  his  work  on  "  Disease  of  Joints,"  and  by 
Bryant  in  the  Medical  Times  and  Gazette^  1869,  is  w'cll  illus- 
trated in  Cases  I.,  IV.,  and  V.  In  the  first  there  was  a  sinus 
above  the  crest  of  the  ileum  and  perforation,  and  in  Cases  IV. 
and  V.  there  was  a  large  abscess  pointing  above  Pouparfs 
ligament  and  perforation  of  the  acetabulum  ;  while  in  Case 
VII.  there  was  a  large  abscess,  no  perforation,  but  disease 
of  the  rim  of  the  pelvis.  In  Cases  II.,  V.,  and  VI.,  there 
is  enlargement  of  the  liver,  and  in  Case  VI.  there  was  a  trace 
of  albumen  before  the  operation,  but  there  has  been  none 
since.  In  Case  VII.  there  is  reason  for  thinking  that  there  is 
an  hereditary  syphilis.     Tlie  advancing  disease  of  the  bones 


IS 

of  tlie  pelvi?,  as  well  as  the  shaft,  precludes  all  hope  of  re- 
covery. 

The  acetabulum  was  extensively  diseased  in  Cases  I.,  11., 
IV.,  v.,  and  VII.,  while  it  was  only  roughened  in  Case  VI.  The 
shaft  of  the  femur  in  Cases  II.,  IV.,  V.,  and  VI.,  was  diseased 
at  the  time  of  the  operation  below  the  point  of  section  ;  and  in 
Case  VII.  the  section  had  to  be  made  below  the  trochanter 
minor  on  account  of  extensive  caries  above  that  point. 

The  appearance  and  condition  of  the  bone  in  the  four  cases 
were  alike  ;  it  was  soft  and  discolored  ;  the  periosteum  seemed 
simply  to  envelop  the  bone  without  being  intimately  attached 
to  it,  so  that  the  shaft  could  be  easily  drawn  out  of  it ;  the 
cut  end  of  the  bone  in  three  of  the  cases  resembled  rather 
coarse  cancellous  tissue,  having  its  meshes  filled  with  a  dark- 
red  granular  material.  The  external  compact  tissue  was  re- 
duced to  a  mere  shell ;  while  in  the  fourth  the  centre  of  the 
bone  had  disappeared,  leaving  a  cavity  which  readily  admitted 
the  fino-er  for  two  inches  or  more.  In  the  latter  case  a  second 
section  was  made  lower  down,  but  only  to  find  the  shaft  in  the 
same  diseased  condition.  In  Cases  II.  and  V.  the  end  of  the 
shaft  became  extensively  eroded;  after  some  time  the  original 
incision  was  reopened  and  an  attempt  made  to  find  the  limit 
of  the  disease,  but  after  exposing  two  or  more  inches  of  the 
shaft,  the  bone  presented  the  same  external  appearance,  and 
on  section  the  central  portion  exhibited  the  same  diseased 
condition  as  at  the  point  of  first  division.  In  Case  IV,  the 
whole  femur  was  removed  through  the  original  incision  made 
for  exsection  of  the  head.  On  examination,  after  removal,  the 
wdiole  bone  was  of  a  dirty  leaden  color  and  very  light  ^  it  re- 
sembled a  bone  from  which  the  periosteum  had  i)een  removed 
by  maceration  ;  the  foramina  for  the  vessels,  to  the  naked  eye, 
did  not  seem  increased  in  number  or  size.  The  periosteum 
was  not  intimately  attached  to  the  bone  at  any  point,  but 
seemed  simply  to  envelop  it.  There  was  no  bleeding  either 
from  the  periosteum  or  bone,  nor  was  there  any  pus  between 
them.. 

There  had  been  no  attempt  at  bony  formation  either  in 
the  periosteum  (involucrumj  or  bone  (osteophytes).  On  longi- 
tudinal section,  after  being  macerated  and  dried,  the  medul- 


VJ 

kry  cavity  was  found  to  be  greatly  enlarged  at  the  expense 
of  the  compact  tissue.  At  the  upper  part  the  cavity  is  filled 
with  cancellous  tissue  for  the  distance  of  one  and  a  quarter 
inch,  it  then  gradually  becomes  less,  until  it  almost  disappears 
at  about  the  middle  of  the  shaft,  and  isthenoidyseen  in  tufts  ; 
the  compact  tissue  is  very  much  thinned,  being  reduced  to  a 
mere  shell  as  it  approaches  either  extremity  of  the  bone, 
being  slightly  thicker  in  the  middle,  where  its  greatest  thick- 
ness amounts  to  only  one  or  two  lines.  The  medullar}' 
cavity  in  many  places  is  perfectly  smooth,  and  has  a  glazed 
appearance  ;  what  remains  of  the  compact  tissue  seems,  to  the 
naked  eye,  normal,  with  the  exception  that  here  and  there  it 
has  a  worm-eaten  appearance,  as  though  a  number  of  Haver- 
sian canals  had  become  enlarged,  showing  a  tendency  of  the 
hard  structure  to  assume  the  appearance  of  cancellous  tissues. 
On  microscopic  examination  of  a  longitudinal  section,  it  pre- 
sents the  appearance  of  healthy  bone.  At  the  lower  end  the 
bone  has  a  worm-eaten  appearance,  and  a  portion  of  it  has  dis- 
appeared. The  weight  of  the  shaft,  after  drying,  is  about  two 
drachms  and  a  half.  The  periosteum,  which  was  removed 
after  death  together  with  the  epiphysis  at  the  knee^i'oint,  is 
iound  to  be  greatly  thickened,  and  in  several  places  there  is 
a  deposit  of  bone,  which  I  am  certain  was  not  there  at  the 
time  of  the  operation.  The  epiphysis  is  perfectly  healthy ; 
there  is  a  thin  layer  of  roughened  bone  attached  to  it. 

The  portion  of  the  shaft  of  the  femur  removed  from  Case 
III.  at  2^ost  mortem  differs  in  some  respects  from  the  above : 
1.  It  was  enlarged  at  the  point  of  section.  2.  The  periosteum 
was  attached  except  where  it  had  fornied  one  of  the  walls  of  the 
abscess.  3.  There  was  an  attempt  at  plastic  inflammation,  as 
shown  by  the  exostosis.  4.  The  bone  on  removal  was  of  a 
perfectly  normal  color.  On  section,  after  maceration  and  dry- 
ing, the  compact  tissue  was  found  reduced  in  thickness,  and 
it  had  a  more  worm-eaten  appearance  than  the  first  specimen  ; 
the  medullary  cavity  was  enlarged  and  partly  tilled  with 
cancellous  tissue. 

In  Cases  II.,  lY.,  Y.,  and  YI.,  there  had  evidently  been  an 
extension  of  disease  from  the  head  of  the  bone  along  the  shaft, 
so  as,  in  one  case  at   least,  to  involve  the  whole  diaphysis. 


20 

and  ill  t\\(»  Dtlier  cases  it  extended  down  at  least  to  tlio  mid- 
dle of  till'  slialt.  It  \V(jiild  fiirtlicniioi-e  seem  jn'obalde  that 
this  alicction  of  the  shaft,  when  once  it  is  well  nnder  way, 
does  not  become  limited,  but  involves  the  Avhole  diaphysis. 
There  is  a  s}>ecimen  in  the  pathological  cabinet  of  the  New 
York  Hospital,  taken  from  a  child  eight  years  of  age,  whose 
thigh  had  been  amputated  at  the  hip-joint,  six  months  after  an 
exsection  of  that  joint  for  extensive  disease,  which  illustrates 
this  condition  of  bone.  The  bone  is  light,  weighing  only  ten 
drachms.  In  external  appearance  it  is  perfectly  normal.  The 
epiphysis  above  the  knee-joint  is  diseased.  In  the  history 
of  the  examination  of  the  limb  no  mention  is  made  of  the 
condition  of  the  periosteum. 

In  the  "  Transactions  of  the  London  Pathological  Society  " 
for  1S72,  page  191,  Mr.  T.  Carr  Jackson  reports  the  case  of  a 
patient  nineteen  years  of  age,  whose  hip-joint  he  bad  excised 
for  disease  of  seven  years'  duration.  The  bone  at  the  point  of 
section  was  soft.,  and  the  compact  bony  tissue  was  reduced  to 
a  mere  shell.  He  made  a  second  section  lo^ver  down,  in  hope  of 
arriving  at  healthy  bone,  but  in  this  he  was  d'lsajjpointed. 
After  the  operation  the  general  health  of  the  patient  improved 
for  a  time,  but  again  became  impaired  on  account  of  the 
discharge  from  numerous  abscesses  in  the  thigh.  After  am- 
putation at  the  hip-joint  he  made  a  good  recovery.  Mr.  Jack- 
son states  :  "  The  femur  after  maceration  weighed  eight  and  a 
quarter  ounces,  against  seventeen  ounces,  the  weight  of  a 
healthy  femur  of  the  same  size.  The  upper  part  had  become 
enlarged  and  rounded,  while  stalactitic  processes  of  somewhat 
porous  but  compact  bone  of  irregular  shape,  and  varying  in 
size,  project  at  various  points.  .  .  .  The  posterior  part  of  the 
external  condyle  is  softened." 

On  section,  it  is  seen  that  the  merest  outside  shell  of  bone 
remains.  At  the  upper  part  a  little  cancellous  tissue  remains, 
and  also  for  one  and  a  quarter  inch  from  the  articular  sur- 
face of  the  condyles  upward.  The  rest  of  the  shaft  is  an  empty 
cavity,  with  a  little  fatty  matter  in  it.  The  external  compact 
tissue  alone  renuxins  nowhere  thicker  than  one  or  two  lines. 
The  whole  bone  mav  be  said  to  have  underironc  an  extensive 


21 

•j.itropliic  process,  anl  reiiiiiiiis,  while  preserving  its  external 
form,  but  a  skeleton  of  itself. 

Mr.  Holmes  reports  a  case  in  "  St.  George's  Hospital  Re- 
ports" (vol.  1.,  page  147),  where  amputation  was  ])erformcd  for 
extensive  disease  about  the  hip-joint,  and  where  the  femur 
was  broken  near  its  head  in  attempting  to  throw  the  head  of 
the  bone  out  in  exsection.  The  femur  was  found  soft  and  dis- 
eased at  both  ends. 

In  the  same  paper  Mr.  Holmes  says:  "It  must  often  have 
struck  surgeons,  when  excising  a  joint,  that  the  operation  has 
heen  put  off  too  long.  The  bone  is  soft,  and  its  periosteum 
peels  oif  so  readily  that  much  care  is  necessary  on  the  part  of 
the  assistant  to  avoid  exposing  it  below  the  surface  of  the  sec- 
tion. The  compact  wall  appears  thinned,  and  the  cancellous 
tissue  confused,  crumbling,  and  filled  with  a  somewhat  puru- 
lent-looking marrow."  He  advocates  amputation  in  these 
•cases. 

Mr.  Annandale,  in  his  paper  on  the  "  Pathology  and  Treat- 
ment of  '  Hip  '-Disease,"  on  page  13  makes  the  following  re- 
marks :  "  I  have  met  with  two  cases  of  hip-disease  in  which 
the  whole  femur,  ileum,  and  probably  other  of  the  bones,  w^ere 
diseased  through  their  whole  structure;"  and  on  page  27  re- 
ports a  case  in  which  "  the  bone  was  so  soft  that  it  had  to  be 
removed  in  pieces.  In  this  way  the  neck,  head,  and  great 
trochanter,  were  removed.  The  wound  did  not  completely 
heal,  so  it  was  again  enlarged,  and  two  inches  of  the  shaft  of 
the  femur  removed.  The  shaft  of  the  bone  where  divided 
w^as,  however,  diseased  in  the  same  way.''''  The  patient  died 
six  months  later. 

Dr.  Sayre,  in  his  work  on  "  Orthopedic  Surgery,"  reports 
having  seen  a  case  in  which  Dr.  Spencer,  of  Watertown,  X. 
Y.,  had  removed  "  nearly  the  entire  shaft  of  the  femur,  and 
perfect  recovery  took  place."  He  does  not  state  tlie  condition 
•of  the  bone  removed,  or  what  he  considers  a  "  perfect  recovery." 

In  looking  over  the  "  table  "  of  exsections  in  the  above- 
mentioned  work  I  find  that  in  lilteen  cases  the  section  was 
made  Ijelow  the  trochanter  minoi",  on  account  of  disease  of  the 
shaft;  of  these  seven  recovered  and  e'lght  died.  Of  the  seven 
who  recovered  the  conditioii   of  the  bone  in  two  cases  is  re- 


22 

ported  as  ht'iii^  necrosed,  in  two  there  reinaiiuMl  a  simis,  jukI 
in  the  remaining  cases  no  mention  is  made  of  tlie  condition  of 
the  limb  at  the  point  incised.  The  cause  ot  death  in  one  of 
these  cases  was  tetanus. 

Out  of  lift^-nine  cases  of  exsection  twenty  are  reported  a& 
having  died  ;  in  two-fiftlis  of  these  the  shaft  was  diseased,  and 
section  liad  been  made  below  the  trochanter  minor. 

The  treatment  of  fracture  of  the  shaft,  when  occurring  at 
the  time  of  exsection,  must  depend  on  the  condition  of  the 
bone.  If  the  probabilities  are  that  the  shaft  is  simply  atro- 
phied, as  must  have  been  the  condition  in  the  two  cases  re- 
ported by  Dr.  Sayre,  it  should  be  treated  as  any  other  fracture^ 
But  if  the  shaft  is  diseased,  as  in  Case  IV.,  either  exsecti(jn  of 
the  whole  femur  or  amputation  at  the  hip-joint  seems  to  be  the 
only  alternative. 

The  question  as  to  the  nature  of  the  changes  in  the  bones 
mentioned  above  I  am  unable  satisfactorily  to  solve.  The 
condition  of  the  ])eriosteum,  caries  of  the  lower  end  of  th& 
shaft,  and  changes  in  the  medullary  cavity,  as  well  as  caries 
of  the  end  of  the  shaft  in  two  cases  later,  in  my  own  ca^'es» 
disease  of  the  epiphyses  in  the  specimen  in  the  pathological 
cabinet  of  the  Xew  York  Hospital,  and  the  osteophytes  and 
abscesses  in  Mr.  Jackson's  case,  all  seem  to  point  to  some 
chronic  inflammatory  process  rather  than  to  simple  atrophy  of 
the  bone.  I  am  satisfied  that  the  disease  of  the  shaft,  in 
Cases  II.,  v.,  and  \l.,  is  the  cause  of  the  persistence  of  the 
discharge,  and  I  do  not  think  that  anything  short  of  an  ampu- 
tation at  the  hip-joint  would  afford  relief,  but  the  presence  of 
enlargement  of  the  liver  contraindicates  a  resort  to  the  ulcera- 
tion. 

I  know  of  no  means  of  ascertaining  the  condition  of  the 
shaft  before  commencing  to  operate,  excei)t  that  cases  of  dis- 
organization of  the  joint,  of  long  standing,  should  be  looked 
upon  with  suspicion. 

In  regard  to  the  question  when  rest  and  mechanical  treat- 
ment should  give  place  to  exsection,  my  own  cases  show  only 
the  result  of  too  long  delay.  In  hospital  cases,  at  least,  it 
seems  to  me,  exsection  should  be  performed  as  soon  as  it  can 
be  satisfactorily  proved  that  there  is  dead  bone  in  thejoint^ 


23 

for,  as  a  rule,  recovery  by  natural  irieaus  seldom  takes  place 
in  these  cases,  and  the  danger  of  the  occurrence  of  secondary 
disease  of  the  liver  and  kidneys  in  these  cases  must  not  be 
lost  sight  of. 

Since  this  paper  went  into  the  hands  of  the  printer,  the 
patient  recorded  as  Case  VII.  lias  died  from  exhaustion.  At 
post-moHem  examination  the  end  of  the  lemur  for  about  one- 
quarter  of  an  incli  wa.-  found  necrosed  and  surrounded  by  an 
involucruin.  The  ischium  was  separated  from  the  other 
bones  and  carious  ;  the  anterior  portion  of  the  ileum,  including 
the  anterior-inferior  spine,  was  extensively  diseased,  as  well  as 
the  whole  acetabulum.  On  the  inner  surface  of  the  ileum, 
about  its  middle,  there  was  a  spot  of  carious  bone  about  three- 
quarters  of  an  inch  in  diameter  which  had  almost  eaten  through 
the  bone,  and  there  was  some  disease  on  the  crest  of  the  ileum. 
The  femur,  with  the  exception  mentioned  above,  was  perfectly 
healthy.  There  was  no  perforation  of  the  acetabulum,  nor 
thickening  of  the  periosteum. 

I  have  lately  received  a  note  from  Dr.  H.  G-.  P.  Spencer, 
of  Watertown,  ]N".  Y.,  in  reply  to  an  inquiry  in  regard  to  the 
case  mentioned  by  Dr.  Say  re,  in  his  recent  work  on  "  Ortho- 
pedic Surgery,"  and  referred  to  in  my  paper,  in  which  he 
removed  the  greater  portion  of  the  femur.  The  patient  was 
a  boy  of  about  twelve  years  of  age,  who  had  had  disease  of 
the  hip-joint  since  he  was  a  child,  and  who,  a  few  days  before 
the  operation,  had  fallen  and  fractured  the  femur  at  its  lower 
third. 

At  the  operation  the  head  of  the  bone  was  found  lying 
loose  in  the  acetabulum.  The  periosteum  was  entirely  sepa- 
rated from  the  shaft  to  some  distance  before  the  point  of 
fracture,  except  a  narrow  strip  on  its  outer  aspect.  The  bone 
was  dead,  except  at  the  attachment  of  the  strip  of  periosteum. 
Section  was  made  just  below^  the  point  of  fracture;  but,  as 
the  bone  seemed  unhealthy  at  this  point,  a  second  section  was 
made  lower  down.  No  invohicrum  had  formed.  The  limb 
was  kept  extended  until  new  bone  had  formed. 

At  the  present  time,  a  number  of  years  since  the  operation, 
the  patient  has  good  motion  at  his  hip-joint,  and  can  walk 
miles  witli  the  aid  of  onlv  a  cane.     The  shortening  is  only 


24 

three  inches.  Dr.  Sayre,  who  has  the  speeiincn  in  his  imiseum, 
has  kindly  allowed  nie  io  examine  it,  and  to  him,  as  M'ell  as 
to  Dr.  Si>eiieer,  I  am  under  great  ohlif^ations. 

The  liead  of  the  femur  is  se[)arated  from  the  shaft,  and  is 
cai-ious.  The  upper  ])()i-tion  of  tlie  shaft,  tor  the  distance  ot 
an  inch  or  more,  is  surrounded  b}'  an  irre^nilar  deposit  of 
bone.  The  external  comi)act  tissue  does  not  seem  to  ho.  re- 
duced in  thickness,  nor  is  the  medullary  cavity  enlarged. 
Tliere  seems  to  have  been  a  total  necrosis  of  the  np])er  two- 
thirds  of  the  shaft. 


THE  FOFUMR  SCIENCE  MONTHLY 


L.    YOUMANS 


This  periodical  was  started  {in  1872)  to  promote  the  diffusion  of  valuable  scienli/ie 

knowledge,  in  a  readable  and  attractive  form,  among  all  classes  of  the 

community,  and  has  thus  far  met  a  want  supplied  by  no 

other  mcu'-a'.iiie  in  the  L'nited  States. 


Ten  volumes  have  now  appeared,  which  are  tilled  with  iiistrnetive  and  iiiti-rcstiuc  aril,  les  and  ab- 
stracts of  articles,  original,  selected,  translated,  and  illustrated.  Ironi  the  jieus  of  the  leading  scientific  men 
of  difterent  countries.  Accounts  of  important  scientific  discoveries,  the  application  of  science  to  the  prac- 
tical arts,  and  the  latest  views  put  forth  concerninfr  natural  phenomena,  have  been  civen  hyu'imiutif  of  the 
hl-rhest  authority.  Prominent  attention  has  been  also  devoted  to  tho.se  various  .sciences  which  help  to  a 
better  understanding  of  the  nature  of  man,  to  the  lnarin<;s  of  science  upon  the  questions  of  society  and 
government,  to  scientific  education,  and  to  the  conflicts  which  spring  from  the  progressive  nature  of  scien- 
tific knowledge. 

The  Popular  Sciknce  Monthly  has  long  since  ceased  to  be  an  experiment.  It  has  passed  into  a 
circulation  far  beyond  the  most  sanguine  hopes  .it  fii-st  entertained,  and  the  cordial  and  Intelligent  approval 
which  it  has  everywhere  met,  shows  thiit  its  close  and  instructive  discussions  have  been  Vi-il  a]ipreciatert 
bv  the  reading  portion  of  the  Amerie:ui  people.  It  has  not  been  its  policy  to  make  boastful  ].ruioises  of 
great  things  to  be  done  In  the  future,  but  rather  to  appeal  to  what  it  has  already  accomplished  as  giving 
it  a  claim  upon  popular  patronage.  But  no  pains  will  be  spared  to  improve  it  and  make  it  still  more  worthy 
of  liberal  support,  and  still  more  a  necessity  to  the  cultivated  classes  of  the  coimtry. 

The  following  quotations  illustrate  the  way  it  has  been  habitually  spoken  of  liy  the  press: 

■'  This  is  a  highly-auspicious  beginning  of  a  use- 
ful and  much-needed  enterprise  in  the  way  of  pub- 
lication, for  which  the  public  owe  a  special  debt  of 
obligation  to  Messrs.  T).  Appleton  &  Co"— Boston 


"  That  there  is  a  place  for  The  Popular  Science 
Monthly,  no  one  can  doubt  who  has  watched  the 
steady  increase  of  interest  in  scientific  investigation 
manifested  in  this  country,  not  only  by  a  select  class, 
but  by  the  entire  community." — New  York  'Hmes. 

"  We  think  it  is  not  too  much  to  say  that  this  is 
the  hest  Jifst  number  of  any  magazine  ever  pub- 
lished in  America." — Neiv  York  World. 

■■  A  journal  which  promises  to  be  of  eminent 
value  to  the  cause  of  popular  education  in  this 
country." — New  York  Trllrttne. 

•  ••  It  is,  beyond  comparison,  the  best  attempt  at 
iournalism  of  the  kind  ever  made  in  this  country." 
— Home  Journal. 

"It  is  just  what  is  wanted  by  the  curious  and 
progressive  mind  of  this  country,  and  ought  to  be 
widely  circulated." — Neiv  York  Evening  Post. 

•'■  It  is  the  first  successful  attempt  in  this  country 
to  popularize  science  in  the  pages  of  a  monthly."— 
X.  Y.  School  Journal. 

"The  Monthly  has  more  than  fulfilled  all  the 
promises  which  the  publishers  made  in  the  pro- 
spectus of  \mh\u"Mon.'^ — Xiagnra  Falls  Gazette. 


Gazette 

"  This  new  magazine,  in  oar  estimation,  has  more 
merit  than  the  whole  brood  which  have  preceded 
it." — Oswego  Press. 

"  In  our  opinion,  the  riglit  idea  has  been  hapi>ily 
hit  in  the  plan  of  this  new  monthly."— ^^//^'cA' 
Courier. 

"This  is  one  of  the  very  best  periodicals  of  its 
kind  published  in  the  world.  Its  corps  of  contribu- 
tors comprise  many  of  the  ablest  minds  known  to 
science  and  literature.  It  is  doing  a  great  and  n.ible 
work  in  popularizing  science,  promoting  the  growth 
of  reason,  and  leveling  the  battlements  of  old  su- 
perstitions reai'ed  in  the  childhood  of  om  race  be- 
fore it  was  capable  of  reas.  ..ing."— T*/**  American 
Medical  Journal,  St.  Louis,  Mo. 

"This  magazine  is  worth  its  weight  in  gold,  for 
its  service  in  educating  the  people."—  Tfie  Amencan 
Journal  of  Education.  St.  Louis.  Mo. 


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B.  .irPLETOX  cV'   CO..   riihlis/,n:'<. 

549  &  65 1  Broadway,  NTeW  Yoik. 


APPLETONS' 

AMERICAN  CYCLOPi^^DIA. 

Entinly  rewritUn   by  the  ablest  writers  on  ever}'  subject.       Printed  /rum  tirw   type, 
and  illustrated  with  Srjcral  Thousand  Engravings  and  Maps. 

Tlic  work  originally  published  under  the  title  of  The  New  American  Cyclopaedia  wu» 
coiunletud  in  1863,  since  which  time  the  n'ide  circulation  which  it  lias  attained  in  all  parte  of 
the  United  States,  and  the  signal  develorincnts  which  have  taken  place  in  every  branch  of 
science,  literature,  and  art,  have  inducecl  the  editors  and  publishers  to  submit  it  to  an  exact 
and  thorough  revision,  and  to  issue  o,  new  edition  entitled  Tue  Amekican  CvcLOP^niA. 

Within  the  last  ten  years  the  progress  of  discovery  in  every  department  of  knowledge 
has  made  a  new  work  of  reference  an  imperative  want. 

The  movement  of  political  affairs  has  kept  pace  with  the  discoveries  of  science,  and  their 
fi-uitful  application  to  the  industrial- and  useful  arts  and  the  convenience  and  refinement  of 
social  life.  Great  wars  and  consequent  revolutions  have  occurred,  involving  national  changes 
of  peculiar  moment.  The  civil  war  of  our  own  comitrj',  which  was  at  its  neight  when  the 
last  volume  of  the  old  work  appeared,  has  happily  been  ended,  and  a  new  course  of  com- 
mercial and  industrial  activity  has  been  commencecl. 

Large  accessions  to  our  geographical  knowledge  have  been  mnde  by  the  indefatigable 
explorers  of  Africa. 

The  great  political  revolutions  of  the  last  decade,  with  the  natural  result  of  the  lapse  of 
time,  have  brouj'ht  into  public  \'iew  a  multitude  of  new  men,  w^hose  names  are  in  every 
one's  mouth,  and  of  whose  lives  every  one  is  curious  to  know  the  particulars.  Great  bat- 
tles have  been  fought,  and  important  sieges  maintained,  of  whicli  the  details  are  as  yel 
preserved  only  in  tlie  newspapers,  or  in  tno  transient  publications  of  the  day,  but  which 
ought  now  to  take  their  place  in  permanent  aud  authentic'history. 

In  preparing  the  present  edition  for  tlie  press,  it  has  accorclinglv  been  the  aim  of  the 
editors  to  bring  down  the  information  to  the  latest  possible  dates,  and  to  iumish  an  accurate 
account  of  the  most  recent  discoveries  in  p^ience,  of  every  fresh  production  in  literature,  and 
the  newest  inventions  in  the  practical  arts,  as  well  as  to  give  a  succinct  and  original  record 
of  the  progress  of  political  and  historical  events. 

The  work  has  been  begun  after  long  aud  careful  preliminary  labor,  and  with  the  ihost 
lunple  resources  for  cairj'ing  it  on  to  a  successful  termmation. 

rJonc  of  the  original  stereotype  plates  have  been  used,  but  every  page  has  been  printed 
on  new  type,  foiming  in  fact  "a  new  Cyclopccdia,  with  the  same  plan  and  compass  as  its 
predecessor,  but  with  a  far  greater  pecuniary  expenditure,  and  with  such  improvements  m 
its  composition  as  have  been  suggested  by  longer  experience  and  enlarged  knowledge. 

The  illustrations,  which  are  uitroduceu  for  the  first  time  in  the  present  edition,  have 
been  added  not  for  the  sake  of  pictorial  eftect,  but  to  give  greater  lucidity  and  force  to  the 
explanations  in  the  text.  They  embrace  all  branches  of  science  and  of  natural  history,  aud 
depict  the  most  famous  and  remarkable  feitures  of  scenery,  architecture,  and  art^  as  well  as 
the  various  processes  of  mechanics  and  manufactures.  "Although  intended  for  mstructiou 
rather  than  embellishment,  no  pains  have  been  spared  to  insure  their  artistic  excellence ; 
the  cost  of  their  execution  is  enormous,  and  it  is  believed  that  they  will  find  a  welcome  re- 
ception as  an  admirable  feature  of  the  Cvclopa;dia,  and  worthy  of  its  high  character. 

This  work  is  sold  to  subscribers  only,  ;)ayable  on  delivery  of  each  volume.  It  is  now 
completed  in  sLxteen  large  octavo  volumii,  each  containing  over  800  pages,  fullv  illustrated 
with  several  thousand  Wood  Engravings,  and  with  numerous  colored Xithograpnic  Maps. 

PRICE    AND    STYLE    OF    BINDING. 

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***  Specimen  pages  of  the  American  Cyclopedia,  showing  type,  illustrations,  etc., 
will  be  sent  gratis,  on  application. 

D.    AFPLETON   &   CO.,  Publishers, 

549  &  551  Broadway,  New  York. 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

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DATE  DUE 

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Exsection  of_the  hip'ioint  ' 


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